In this paper, I argue for a fundamentally different kind of moral luck, Patient Moral Luck (PML). Unlike traditional moral luck, PML concerns the amount of moral consideration that different moral patients — that is, creatures (including human beings) with moral status — will be owed, independent of factors in their control. PML, I argue, entails that morality itself appears to sanction and even obligate actions which, along predictable patterns, involve repeatedly failing to equally consider certain moral patients - (...) and repeatedly the same people - over sustained periods of time, through no fault of their own. And often these people will be members of groups who are already worse off through no fault of their own, thus exacerbating unjust inequalities. I defend the existence and normative puzzle of PML by introducing the notion of “moral force” - roughly, the amount of considerative weight a given moral patient is owed by some deliberating agent or group of agents. I then argue that this will vary widely between different moral patients through no fault or credit of their own. This, I claim, is inconsistent with the intuition that supports Equal Consideration principles in moral theory. I conclude by considering how we can minimize or mitigate PML without a radically revisionary normative theory. (shrink)

Objective: Patients' satisfaction is one of the most important goals in complete denture therapy, and there are many factors influencing this parameter. This study aimed to determine patient satisfaction with conventional removable complete denture made by clinical year students at the Faculty of Dentistry, Al Azhar University - Gaza. Methods: A sample of 85 patient who had conventional removable complete denture made by clinical year students at the Faculty of Dentistry Al Azhar University - Gaza filled a questionnaire (...) two months after denture insertion. The questionnaire involving four sections including personal information, history, denture evaluation in aspects of mastication, speech, aesthetics and retention, and patient comfort. Results: Of the 85 patient studied, 81% were males, and the mean age was 60.3 years SD+-9.64. The majority (n= 67, 79 %) lost their teeth because of bad oral hygiene. The overall satisfaction level was (92.1%), and patients were more satisfied with their upper denture. A significant association was found between the patient satisfaction and prior denture use experience (p=0.013). No significant correlation was established between the patient satisfaction and their gender (p=0.188), age group (p=0.640) and employment status (p=0.667).Conclusion: The patients have shown a high level of overall satisfaction. A significant association was found between the overall satisfaction level of patients and prior denture use experience. No statistically significant association was observed between the overall satisfaction level of patients and with each of age group, employment status and gender. (shrink)

Disclosure in clinical practice is aimed at promoting patient autonomy, usually culminating in patient choice (e.g., to consent to an operation or not, or between different medications). In medical ethics, there is an implicit background assumption that knowing more about (X) automatically translates to greater, or more genuine, autonomy with respect to one's choices involving (X). I challenge this assumption by arguing that in rare cases, withholding information can promote a patient's autonomy (understood as the capacity for (...) rational choice in alignment with one's values and goals). (shrink)

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, especially when (...) principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

The notion that the family is the unit of care for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine (...) — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds. (shrink)

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can (...) find themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)

Epileptogenesis involves an increase in excitatory synaptic strength in the brain in a manner similar to synaptic potentiation. In the present study we investigated the mechanisms of short-term synaptic potentiation in patients with focal epilepsy by using 5 Hz repetitive transcranial magnetic stimulation (rTMS), a non invasive neurophysiological technique able to investigate the mechanisms of synaptic plasticity in humans. Ten patients with focal idiopathic cortical epilepsy were studied. 5 Hz-rTMS (10 stimuli-trains, 120% of motor threshold, RMT) was delivered over the (...) first dorsal interosseus (FDI) motor area of both (affected and unaffected) hemispheres. Changes in the motor evoked potential (MEP) size in the FDI muscle during the trains and the RMT were measured and compared between the hemispheres. 5 Hz-rTMS was also delivered in a group of healthy subjects over both hemispheres. 5 Hz-rTMS in patients elicited a reduced MEP facilitation compared to normal subjects. The reduced MEP amplitude was more evident in the affected hemisphere than in the unaffected hemisphere. RMT in the affected hemisphere was higher than in the unaffected hemisphere and in healthy subjects. Our findings showing a decreased response to 5 Hz-rTMS over the affected hemisphere, differently from the expected results suggest a reduced cortical excitability in epileptic patients. We hypothesize an altered balance between excitatory and inhibitory circuits in epileptic patients under chronic therapy. (shrink)

During the recent Ebola epidemic, some commentators and stakeholders argued that it would be unethical to carry out a study that withheld a potential treatment from affected individuals with such a serious, untreatable disease. As a result, the initial trials of experimental treatments did not have control arms, despite important scientific reasons for their inclusion. In this paper, we consider whether the duty to rescue entails that it would be unethical to withhold an experimental treatment from patient-participants with serious (...) diseases for which there are no effective treatments, even when doing so is scientifically necessary to test the effectiveness of the treatment. We argue that the duty to rescue will rarely apply. The context of medical research also throws new light on the content of the duty to rescue, since the interests of future patients—who stand to benefit from the fruits of medical research—are relevant to whether the duty applies. (shrink)

Individual health assessments (IHAs) for asymptomatic individuals provide a challenge to traditional distinctions between patient care and non-medical practice. They may involve undue radiation exposure, lead to false positives, and involve high out-of-pocket costs for recipients. A recent paper (Journal of the American College of Radiology 13(12): 1447–1457.e1, 2016) has criticised the use of IHAs and argued that recipients should be classified as ‘presenters’, not ‘patients’, to distinguish it from regular medical care. I critique this classificatory move, on two (...) grounds: one, it is conceptually suspect. Two, it obviates the medical ethics framework for IHAs, potentially exposing recipients of IHAs to lower standards of oversight and protection. Responsible regulation of IHAs will be easier to ethically justify if those seeking IHAs are considered patients and not merely presenters. (shrink)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

The underreporting of suspected adverse drug reactions hinders pharmacovigilance. Solutions to underreporting are oftentimes directed at clinicians and health care professionals. However, given the recent rise of public inclusion in medical science, solutions may soon begin more actively involving patients. I aim to offer an evaluative framework for future possible proposals that would engage patients with the aim of mitigating underreporting. The framework may also have value in evaluating current reporting practices. The offered framework is composed of three criteria that (...) are bioethical, social-epistemic, and pragmatic: (i) patients should not be exposed to undue harms, e.g., nocebo effects; (ii) data should be collected, analyzed, and communicated prioritizing pharmacovigilance’s aims, i.e., free from industry bias; and (iii) proposals should account for existing and foreseeable pragmatic constraints like clinician ‘buy in’ and existing reporting infrastructure. Proposals to engage patients in pharmacovigilance that fulfil or address these criteria are preferable to those that do not. (shrink)

Currently, documentation on the effects of psychedelics on psychosis appears scarce. In the present case, a higher-dose LSD experience during acute paranoid psychosis before the initiation of antipsychotics induced feelings of love, which resolved the majority of the symptoms of the paranoid psychosis in one session, leading the person to reconnect with his family and seek treatment in a psychiatric hospital. The session did not resolve schizoaffective disorder, however. More than a decade later, while using the antipsychotic aripiprazole, concurrent self-administration (...) of ketamine induced psychedelic effects that appeared to allow for practicing 'grounding' of psychotic thoughts. Immediately afterwards, daily self-administration of psycholytic doses of LSD for four weeks caused a mood-enhancing effect that enabled the patient to successfully discontinue aripiprazole without the return of psychotic symptoms. No psychotic or other noticeable symptoms could be observed during two interviews conducted in the two months following the discontinuation of the antipsychotic. -/- The mechanisms of action remain unexplored, and their possible generalizability to other cases remains unclear, but the observations may serve as a basis for further research. It may, for example, be that chronic use of LSD induces a tolerance to its psychedelic effects but not to its anti-inflammatory or other possibly unknown effects, which may be related to the observed mood-enhancing effect. A preclinical study from 1971 appeared consistent with the claimed effect. -/- In the present case, paranoia, i.e., the hypersensitivity to potential threats, was partly due to childhood trauma, partly intentionally induced by military training, and partly accentuated by war experiences. It could not be 'turned off'. Fear related to the uncertainty of survival formed the core of psychosis; without the fear, psychosis would likely not have existed. Paranoid psychosis presented itself as a biased estimation of probabilities of possible adverse outcomes, as a mismatch between the past and the present. (shrink)

—One of the promising applications of wireless sensor networks (WSNs) is monitoring of the human body for health concerns. For this purpose, a large number of small sensors are implanted in the human body. These sensors altogether provide a network of wireless sensors (WBANs) and monitor the vital signs and signals of the human body; these sensors will then send this information to the doctor. The most important application of the WBAN is the implementation of the monitoring network for (...) class='Hi'>patient safety in the hospital environment. In this case, supporting patients’ mobility is one of the basic needs, which has been underestimated in recent studies. The problem that involves providing the required energy for the units used in this type of network is challenging; for this reason, sent/ received units with very low power consumption and with a very small radius are used in order to save energy. The resulting small sending range, leads to the lack of support for patients' mobility. In this paper, the AD HOC mode is suggested for use to establish a network and a multi-path routing algorithm, for the purpose of importing patients’ mobility in hospital setting. The results of the simulation show that in addition to supporting patients' mobility, the use of the proposed idea instead of previously presented protocols, reduces delays in data transmission and energy consumption; and it also increases the delivery rate depending on the destination and the lifetime of the network, while on the other hand, it increases routing overhead. (shrink)

The IPAP Schizophrenia Algorithm was originally designed in the form of a flow chart to help physicians optimise the treatment of schizophrenic patients. We examined the current version from the perspective of recent work on terminologies and ontologies thereby drawing on the resources of Basic Formal Ontology, and this with the objective to make the algorithm appropriate for Semantic Web applications. We found that Basic Formal Ontology is a rich enough theory to represent all the entities involved and that applying (...) the theory to the IPAP schizophrenia algorithm results in a representation that can be used by software agents to perform monitoring and control in a referent tracking environment. (shrink)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: -/- The main aim of this review will be to assess the effects of changing practitioner empathy or patient expectations for all conditions. The main objective is to conduct a systematic review of randomised trials where the intervention involves manipulating either (a) practitioner empathy or (b) patient expectations, or (c) both.

n hospitals, preliminary health assessments are typically performed by doctors, involving direct physical contact with patients. This practice not only exposes healthcare workers to potential infectious diseases but also consumes valuable time that could be better spent on critical cases. Routine checks, which could be automated, often contribute to longer patient wait times and reduced overall efficiency in hospital operations. The COVID-19 pandemic has further emphasized the importance of minimizing human-to-human contact, with the World Health Organization (WHO) advocating for (...) social distancing and contactless interaction to prevent the spread of the virus. This situation highlights a pressing need for innovative solutions that maintain highquality care while reducing direct physical contact. This project addresses the challenge by developing an Autonomous Smart Medical Assistant Robot capable of performing contactless preliminary health testing. Designed to automate routine assessments, the robot significantly reduces doctors’ workload, improves hospital workflow, and enhances patient management. It has been precisely designed and simulated using Autodesk Fusion 360, ensuring mechanical accuracy, while its control system is programmed using the Arduino IDE, allowing seamless integration of health-monitoring sensors and autonomous functionality. Beyond health assessments, the robot also provides emotional support to patients and can be used for the transport of medical supplies between healthcare providers and patients. This multifunctional capability not only enhances safety by limiting unnecessary exposure but also introduces operational efficiency and emotional care into medical settings. The implementation of this robot represents a step toward smarter, safer, and more compassionate healthcare environments. (shrink)

Effective knowledge and practice regarding diabetic foot care among diabetic patients are crucial in reducing the risk of complications of foot ulcers and amputations. This cross-sectional study evaluates the levels of knowledge and practice of diabetic foot standards of care among Libyan diabetic patients. Thus, a total of 481 Libyan patients participated in 2024. Data were collected through a validated self-designed questionnaire that assessed foot care knowledge and practice. Scores were assigned for each yes response, and a median score was (...) calculated to categorize participants as having good or poor knowledge and practice. The association between socio-demographic and diabetes-related factors with knowledge and practice was analyzed using the Chi-square test. The findings revealed that 74.1% of the participants had poor knowledge about the standards of diabetic foot care and 72.0% demonstrated poor practice related to diabetic foot care. A significant association was found between variables such as age, gender, and diabetes duration with knowledge and practice (p<0.05). 36.2%, reported having received formal education on diabetic foot care. This study recommends enhancing educational efforts and increasing physician involvement in foot care strategies. The majority of Libyan diabetic patients demonstrate a lack of knowledge and poor practice regarding diabetic foot care, which increases their risk of foot ulcers and amputations. This situation highlights the urgent need for an enhanced educational campaign focused on foot hygiene and care, as well as increased involvement of healthcare providers to deliver clear practical guidance preventing and an early examination to avoid complications in clinical practice. (shrink)

Treatment adherence is a critical component of epilepsy management. Antiepileptic drug side effects affect adherence and may result in the discontinuation of medication. This study aimed to investigate the association between antiepileptic drug side effects and medication adherence among Libyan patients with epilepsy while identifying predictors of adherence. A cross-sectional study was conducted at Tripoli University Hospital involving 200 adult epilepsy patients. Adherence was assessed via a self-report tool dichotomized as adherent/ non-adherent if patients stopped medication due to side effects. (...) Side effects were evaluated using the Side Effects of Antiepileptic Drugs questionnaire. Logistic regression analyzed predictors of adherence, including antiepileptic drug use, therapy regimen, and side-effect profiles, with p<0.05 declared association. The overall adherence rate was 87.0%. Higher adherence was observed in older age groups, 95.8% in patients aged 51-60, 89.4% in married patients, and 91.0% in university-educated patients. Patients on monotherapy and those seizure-free in the preceding month demonstrated better adherence (88.4% and 93.0%, respectively). Valproate users had notably low adherence (52.6%) while carbamazepine and phenytoin users showed higher adherence (89.7% and 91.7%, respectively). Cognitive complaints significantly reduced adherence (76.1% vs. 79.6%), as did aggressive behavior (58.3% adherence). Logistic regression identified two independent predictors: patients on old-generation antiepileptic drugs had 2.7 times higher adherence (AOR=2.702, 95% CI: 1.168-6.249; p=0.02) while cognitive side effects reduced adherence by 86.4% (AOR=0.136, 95% CI: 0.031-0.596; p=0.008). Cognitive side effects predict non-adherence, necessitating routine monitoring. Paradoxically, older antiepileptic drugs correlated with better adherence. Integrating patient-reported metrics and addressing cognitive impacts could optimize epilepsy care, highlighting gaps in side-effect management and advocating personalized strategies in clinical settings. (shrink)

Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to do qua physicians. In this paper, I defend (...) the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values. (shrink)

In this issue, Ahmadi1 reports on the practice of hymenoplasty—a surgical intervention meant to restore a presumed physical marker of virginity prior to a woman's marriage. As Mehri and Sills2 have stated, these women ‘want to ensure that blood is spilled on their wedding night sheets.’ Although Ahmadi's research was carried out in Iran specifically, this surgery is becoming increasingly popular in a number of Western countries as well, especially among Muslim populations.3 What are the ethics of hymen restoration?Consider the (...) role of the physician. Two of the doctors interviewed by Ahmadi reported being in ‘a perpetual state of guilt because of the surgery's inherent aim at deceiving the groom’ and noted their ‘personal conflict’ at being involved in this deception. Yet: "None of the doctors believed that the surgery was unethical, arguing that the girl could be ‘abused’ and ‘can even die’ if she is discovered not … ". (shrink)

Objective: Vascular disorders severely impair the psycho-social status of individuals. Various laser and light systems, which have advantages and disadvantages, including the pro-yellow laser are used for the therapy of these disorders. Aim: The goal of the present study was to investigate the effectiveness and feasibility of the 577 nm pro-yellow laser for a broad range of indications including erythematelangiectatic rosacea, facial erythema, post-acne erythema, facial telangiectasis, hemangioma, genital angiokeratoma, and port wine stain nevus. Methods: A total of 98 patients (...) (25 male, 73 female) older than 15 years who were treated with the pro-yellow laser for vascular disorders at the cosmetology unit between 2017 and 2019 were retrospectively included in the study. Results: The mean rate of recovery was 100% in genital angiokeratoma, 94.4% in spider angioma, 83.3% in facial telangiectasis, 74.8% in erythematotelangiectatic rosacea, 72% in facial erythema + facial telangiectasis, and 68.3% in facial erythema. Over 60% of improvement was observed in most patients with vascular disorders. There was no significant link between the Fitzpatrick skin type and treatment success. Treatment success was significantly low in cases with nasal involvement. Conclusion: The current study concluded that pro-yellow laser is an efficient and safe laser modality that may yield satisfactory outcomes regardless of the different skin types. (shrink)

Patients suffering from depersonalization complain of feeling detached from their body, their mental states, and actions or even from themselves. In this chapter, I argue that depersonalization consists in the lack of a phenomenal feature that marks my experiences as mine, which is usually called “mineness,” and that the study of depersonalization constitutes a neglected yet incomparable probe to assess empirically the scope, role, and even the nature of mineness. Here is how I will proceed. After describing depersonalization (§2) and (...) arguing that it involves a lack of mineness (§3) I will confront a series of objections (§4). I will then spell out what depersonalization can teach us about the scope of mineness (§5), about its role and psychological function (§6) and even about its nature (§7). (shrink)

I defend the feasibility of a medical conscience in the following sense: a medical professional can object to the prevailing medical norms because they are incorrect as medical norms. In other words, I provide an account of conscientious objection that makes use of the idea that the conscience can issue true normative claims, but the claims in question are claims about medical norms rather than about general moral norms. I further argue that in order for this line of reasoning to (...) succeed, there needs to be an internal morality of medicine that determines what medical professionals ought to do qua medical professionals. I utilize a constructivist approach to the internal morality of medicine and argue that medical professionals can conscientiously object to providing treatment X, if providing treatment X is not in accordance with norms that would have been constructed, in light of the end of medicine, by the appropriate agents under the appropriate conditions. (shrink)

A patient is diagnosed with the persistent vegetative state (PVS) when they show no evidence of the awareness of the self or the environment for an extended period of time. The chance of recovery of any mental function or the ability to interact in a meaningful way is low. Though rare, the condition, considering its nature as a state outwith the realm of the conscious, coupled with the trauma experienced by the patient's kin as well as health care (...) staff confronted with painful decisions regarding the patient's care, has attracted a considerable amount of discussion within the bioethics community. At present, there is a wealth of literature that discusses the relevant neurology, that elucidates the plethora of ethical challenges in understanding and dealing with the condition, and that analyses the real-world cases which have prominently featured in the mainstream media as a result of emotionally charged, divergent views concerning the provision of care to the patient. However, there is scarcely anything in the published scholarly literature that proposes concrete and practically actionable solutions to the now widely recognized moral conundrums. The present article describes a step in that direction. I start from the very foundations, laying out a sentientist approach which serves as the basis for the consequent moral decision-making, and then proceed to systematically identify and deconstruct the different cases of discord, using the aforementioned foundations as the basis for their resolution. A major intellectual contribution concerns the fluidity of the duty of care which I argue is demanded by the sentientist focus. The said duty is shown initially to have for its object the patient, which depending on the circumstances, can change to the patient's kin, or the health care staff themselves. In conclusion, the proposed framework represents the first comprehensive proposal regarding the decision-making processes involved in the deliberation on the provision of life sustaining treatment to a patient in a PVS. (shrink)

Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and citizenship (...) of the participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

[English version below] Diese Stellungnahme zielt darauf ab, Empfehlungen für akzeptable Rahmenbedingungen eines Genomischen-Neugeborenen-Screening (gNBS)-Programms in Deutschland zu formulieren, darunter Empfehlungen zu Auswahlkriterien für Zielkrankheiten und zum Management eines gNBS-Programms sowie zur gesetzlichen Neuregulierung. Sie ist Ergebnis eines dreijährigen Forschungsprojektes, das an den Universitäten Heidelberg und Mannheim durchgeführt wurde. An dem interdisziplinären Projekt beteiligt waren Forscher:innen aus den Bereichen Kinder- und Jugendmedizin, Humangenetik, Rechtswissenschaft, Medizinische Psychologie und Medizinethik sowie Vertreter:innen von Patient:innen-Organisationen (Kindernetzwerk e.V. und Deutsche Interessengemeinschaft Phenylketonurie und verwandte (...) angeborene Stoffwechselstörungen e.V.). Das Projekt wurde vom Bundesministerium für Bildung und Forschung (BMBF; seit 2025 Bundesministerium für Forschung, Technologie und Raumfahrt: BMFTR) gefördert und trägt den Titel NEW_LIVES („Genomic NEWborn screening programs – Legal Implications, Value, Ethics and Society” – „Genomische Neugeborenen-Screening-Programme – Rechtliche Implikationen, Werte, Ethik und Gesellschaft“). Die Stellungnahme beginnt mit einführenden Kapiteln zum Hintergrund des gNBS aus Sicht der verschiedenen Fachbereiche und aus Sicht der Gesellschaft, gefolgt von konkreten Empfehlungen für ein zukünftig mögliches gNBS-Pro- gramm in Deutschland. In der Einleitung (1.) werden erste Ergebnisse bisheriger Forschungsprojekte zum gNBS zusammengefasst und die Zielsetzung und Methode, einschließlich der Rolle von Patient:innen-Vertreter:innen bei der Erarbeitung der Stellungnahme werden beschrieben. In Abschnitt 2 („Medizinischer Hintergrund“) werden Entwicklung, Umfang und Ablauf des derzeitigen Neugeborenen-Screening (NBS)-Programms in Deutschland beschrieben und die Besonderheiten eines gNBS-Programms erläutert. Abschnitt 3 („Perspektive von Patient:innen, Eltern und medizinischem Personal“) fasst die Ergebnisse der sozialempirischen Studien zusammen, die im Rahmen des Projektes NEW_LIVES durchgeführt wurden (Fokusgruppen, bevölkerungs-repräsentative Befragung, querschnittliche Online-Befragung) und vergleicht die Ergebnisse mit anderen, internationalen Studien. Abschnitt 3 enthält außerdem eine gemeinsame Stellungnahme der beiden Patient:innen-Organisationen, die am Projekt NEW_LIVES mitgewirkt haben, zum gNBS. Abschnitt 4 („Genomisches Neugeborenen-Screening aus rechtlicher Sicht“) skizziert den rechtlichen Regulierungsrahmen zum gNBS in Deutschland. Abschnitt 5 („Genomisches Neugeborenen-Screening aus ethischer Sicht“) benennt zentrale ethische Herausforderungen des gNBS und formuliert ethische Orientierungsmaßstäbe für ein zukünftiges gNBS-Programm in Deutschland. Da die Neugeborenen diejenigen sind, die an einem gNBS teilnehmen würden und davon profitieren könnten, stellt deren Kindeswohl den zentralen ethischen Orientierungsmaßstab für die Bewertung dar. Die sich in Abschnitt 6 anschließenden Empfehlungen sind aus Sicht aller an der Erarbeitung dieser Stellungnahme beteiligten Fachdisziplinen und der Patient:innen-Organisationen verfasst Darunter sind einerseits transparente Auswahlkriterien für Zielkrankheiten eines gNBS-Programms (Kriterien 1–11). Andererseits werden Empfehlungen für die Einführung, Qualitätssicherung und Nutzenbewertung eines gNBS-Programms formuliert (Kriterien 12–18). Zudem enthält diese Stellungnahme Empfehlungen zur gesetzlichen Neuregulierung. Eine Publikation der Empfehlungen auf Englisch findet sich in Schnabel-Besson et al.: “A multi-dimensional fra- mework for establishing and managing a genomic newborn screening program” (Arbeitstitel; zum Zeitpunkt des Verfassens dieser Stellungnahme in Vorbereitung; DOI der Preprint-Version: 10.1101/2025.06.17.25329 471). - This position paper has the aim of formulating recommendations for what would be an acceptable framework for a genomic newborn screening (gNBS) programme in Germany, including recommendations for selection criteria for target diseases, and for the management of a gNBS programme, as well as for revision of legislation. It is the result of a research project conducted at the Universities of Heidelberg and Mannheim over the course of three years. This interdisciplinary project brought together researchers from the fields of paediatrics and adolescent medicine, human genetics, law, medical psychology, and medical ethics, as well as representatives of patient organisations (Kindernetzwerk e.V., and Deutsche Interessenge- meinschaft Phenylketonurie und verwandte angeborene Stoffwechselstörungen e.V.). The project was funded by the German Federal Ministry of Education and Research (BMBF; since 2025 Federal Ministry of Research, Technology and Space: BMFTR) and is called NEW_LIVES (“Genomic NEWborn screening programs – Legal Implications, Value, Ethics and Society”). The position paper begins with introductory chapters on gNBS from the perspective of the different disciplines, and from a societal viewpoint, followed by concrete recommendations for a possible future gNBS programme in Germany. The Introduction (1.) summarises the initial results of previous research projects on gNBS, and describes the objectives, and methodology, including the role of patient representatives, in the development of the position paper. Section 2 (“Medical Background”) describes the development, scope, and process of the current NBS programme in Germany, and explains the specific features of a gNBS programme. Section 3 (“Perspectives of Patients, Parents, and Medical Staff”) summarizes the results of the social-empirical studies conducted as part of the NEW_LIVES project (focus groups, population-representative survey, cross-sectional online survey), and compares the results with other, international studies. Section 3 also contains a joint statement on gNBS by the two patient organisations that participated in the NEW_LIVES project. Section 4 (“Genomic Newborn Screening from a Legal Perspective”) outlines the legal regulatory framework for gNBS in Germany. Section 5 (“Genomic Newborn Screening from an Ethical Perspective”) identifies key ethical challenges of gNBS, and formulates ethical guidelines for a future gNBS programme in Germany. Since newborns are the ones who would participate in, and benefit from gNBS, their welfare represents the central ethical guideline for the evaluation. The recommendations in Section 6 are written from the perspective of all disciplines, and patient organisations involved in the development of this position paper. These recommendations reflect the consensus of the inter-, and transdisciplinary group of authors, and form the core of the position paper. They comprise 18 criteria for a possible future gNBS programme in Germany. These include, on the one hand, transparent selection criteria for target diseases of a gNBS programme (criteria 1–11). On the other hand, recommendations are formulated for the introduction, quality assurance, and benefit assessment of a gNBS programme (criteria 12–18). This position paper also contains recommendations for new legal regulations. An English version of the recommendations, including the 11 criteria for selecting target diseases and the 7 criteria for programme management can be found in Schnabel-Besson E, Dikow N, Alex K et al.: “A multidimensional framework for establishing and managing a genomic newborn screening program” (working title; in preparation at the time of writing this position paper; doi of preprint version: 10.1101/2025.06.17.25329471). (shrink)

Cite as: -/- Onder, O. (2025). Klinik Karar Destek Sistemleri Bağlamında Tıpta Yapay Zeka Kullanımında Etik Sorun Alanları (Publication No. 949041) [Doctoral dissertation, Istanbul University] YÖK Ulusal Tez Merkezi. -/- The Ethical Aspects of Artificial Intelligence Use in Medicine within the Context of Clinical Decision Support Systems -/- ABSTRACT The increasing use of artificial intelligence (AI) and health technologies in clinical practice will lead to significant transformations in the doctor-patient relationship. Accordingly, it is a critical necessity to investigate how (...) this relationship will change with the integration of AI and health technologies in general, and Clinical Decision Support Systems (CDSS) in particular, and to identify, analyze, and evaluate the ethical issues arising from this transformation. In response to this need, the present study aims to examine the relationship between the doctor, patient, and CDSS, focusing on the asymmetries within this relationship and the ethical dimensions of the principle of responsibility in CDSS-involved decisions. With the integration of CDSS into the doctor-patient relationship, a triadic relationship involving the doctor, patient, and CDSS is expected to gain prominence. From an ethical standpoint, this change must adopt a human-centered approach and be oriented towards enhancing patient well-being. In this context, the study defends, within a normative framework, that CDSS in the triadic clinic should function as a "care-optimizer". The concept of care optimization is elaborated in five main categories: quality of care, patient-centered care, decision-making processes, access and communication, and care practices. Following this, power and epistemic asymmetries emerging in the triadic clinic are examined through an asymmetry analysis grounded in relationalism, and the normative implications of these asymmetries on physician responsibility are evaluated. By analyzing the inherent and contingent dimensions of power asymmetry, along with the categorical and gradual forms of epistemic asymmetry, the study explores their effects on responsibility distribution in the context of meaningful human control and explainability. The theoretical foundation of this study is grounded in the postphenomenological theory of technological mediation, which emphasizes that technologies are not neutral tools but mediators shaping human experience. As a result, the study proposes a normative framework for a healthcare system that prioritizes patient well-being and develops a relational approach to address the complexities of responsibility distribution within the triadic clinic. -/- Key Words: Doctor-patient relationship, Artificial Intelligence Ethics, Clinical Decision Support Systems, responsibility, patient wellbeing -/- ÖZET Yapay zekâ (YZ) ve sağlık teknolojilerinin klinik uygulamalarda artarak kullanılması, hasta-hekim ilişkisinde önemli dönüşümlere yol açacaktır. Bu doğrultuda, genelde YZ’nin ve teknolojilerin, özelde ise Klinik Karar Destek Sistemleri’nin (KKDS) kliniğe entegrasyonuyla, hasta-hekim ilişkisinin nasıl değişeceğinin incelenmesi ve bu değişiklikten neşet eden etik sorunların tespiti, analizi ve değerlendirilmesi önemli bir ihtiyaçtır. Bu ihtiyaca binaen araştırmada, hasta-hekim ve KKDS ilişkisi ile bu ilişkideki asimetrilerin ve KKDS ile alınan kararlarda sorumluluk ilkesinin etik boyutlarının incelenmesi amaçlanmıştır. KKDS’nin hasta-hekim ilişkisine eklenmesiyle hasta-hekim-KKDS olmak üzere üçlü (triadik) bir ilişkinin ön plana çıkacağı söylenebilir. Etik açıdan konuya yaklaşıldığında bu değişiklik insanı merkeze almalı ve buna bağlı olarak hasta refahını arttırmaya yönelik olmalıdır. Bu bağlamda, araştırmada KKDS’nin hasta-hekim ilişkisinde hastanın değerler sistemine odaklanarak, onun tedavi ve bakım kalitesini iyileştirici olması gerektiği normatif bir çerçevede savunulmuştur. Tedavi ve bakım iyileştirme konsepti; bakım kalitesi, hasta odaklı bakım, karar verme süreçleri, erişim ve iletişim uygulamaları gibi kategorilerle detaylandırılmıştır. Ardından, ilişkiselcilik temelinde bir yaklaşım olarak sunulan asimetri analizi ile triadik klinikte ortaya çıkan güç asimetrisi ve epistemik asimetriler kapsamlı bir şekilde incelenmiş ve asimetrilerin hekimin sorumluluğu üzerindeki normatif etkileri değerlendirilmiştir. Güç asimetrisinin içkin ve olumsal boyutları ile epistemik asimetrilerin kategorik ve tedrici görünümleri analiz edilerek; bu asimetrilerin anlamlı insan kontrolü ve açıklanabilirlik bağlamında sorumluluk dağıtımına etkileri analiz edilmiştir. Tüm bu çalışmaların teorik genel çerçevesi olarak, postfenomenolojinin - teknolojilerin nötral araçlar olmadığı, aksine insan tecrübesini şekillendiren aracılar olduğunu savunan - teknolojik aracılık teorisi benimsenmiştir. Bu çalışmanın neticesinde hasta refahını ön planda tutan bir sağlık sistemi için normatif bir çerçeve sunulmuş ve sağlık hizmetlerinde sorumluluk dağıtımındaki karmaşıklıkları çözmeye yönelik ilişkisel bir yaklaşım geliştirilmiştir. -/- Anahtar Kelimeler: Hasta-hekim ilişkisi, Yapay Zekâ Etiği, Klinik Karar Destek Sistemleri, sorumluluk, hasta refahı -/- . (shrink)

Diagnosing flatulence involves a thorough assessment of an individual's symptoms, medical history, and, if necessary, the use of diagnostic tests. Healthcare providers gather information about the patient's medical background and conduct a physical examination to identify any signs of gastrointestinal issues. Dietary habits are evaluated, and potential triggers are identified through an elimination diet. Diagnostic tests such as breath tests, stool analysis, or imaging studies may be performed to further investigate the underlying causes of excessive flatulence. Accurate diagnosis is (...) crucial for effective management and treatment of flatulence, enabling individuals to gain control over their symptoms and address any underlying conditions. (shrink)

Abstract -/- Introduction. The medical sphere is constantly evolving, requiring improved approaches to its organisation and functioning. Advances in medical technology, observable changes in patient needs and growing competition challenge medical institutions to improve their strategies and approaches. Marketing technologies are becoming one of the key tools for achieving strategic goals. -/- Purpose. This article is aimed at studying the peculiarities of the use of marketing technologies in the medical field. The main purpose of the study is to analyse (...) the impact of marketing tools on the development and success of medical institutions. -/- Method (methodology). The methodological approach involves the use of an analytical approach to studying current trends in marketing and their impact on the healthcare sector. The study uses methods of data analysis and comparative analysis of marketing practices in medical institutions. -/- Results. The study found that the use of targeted marketing strategies allows healthcare facilities to attract more patients, increase customer satisfaction and ensure an excellent reputation. The results of the study show a positive impact of the use of marketing tools on changing the perception of medical services by patients. -/- Conclusions. The scope of application of the results is the practical activities of medical institutions seeking to improve their strategy of promotion and interaction with customers. The findings of the study can be used by marketers and managers of healthcare organisations to develop and implement effective marketing strategies. -/- In summary, this article reveals the importance of using marketing technologies in the healthcare sector and provides practical recommendations for their successful implementation. The study emphasises that marketing in the healthcare industry is necessary to increase competitiveness and ensure quality medical care. (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

Crises in therapist-patient relationship can also become a challenge in clinical supervision. However, success and failure in establishing and maintaining constructive relationships in therapy and supervision is not only subject to a lucky fit of personal characteristics (therapist A gets along well/badly with client B; supervisee A gets along well/badly with supervisor C). Rather, we can identify determining field conditions in the overall therapeutic and supervisory situation for this outcome. We do not only focus on the persons involved, but (...) also on their environment, the task to be accomplished together, further framework conditions and the power relations resulting from their mutual influence-in the supervised case of therapy as well as in supervision itself. We want to examine the structure and dynamics of these relationships from a genuine Gestalt psychological perspective. What contributes to a cooperative atmosphere? When do goals get out of sight? What can make the atmosphere hostile? How do such developments become accessible in supervision? (shrink)

Innovative practice involves medical interventions that deviate from standard practice in significant ways. For many patients, innovative practice offers the best chance of successful treatment. Because little is known about most innovative treatments, clinicians who engage in innovative practice might consider including extra procedures, such as scans or blood draws, to gather information about the innovation. Such information-gathering interventions can yield valuable information for modifying the innovation to benefit future patients and for designing scientific studies of the innovation. However, existing (...) guidelines do not say when or whether it is appropriate to add potentially risky information-gathering interventions for these purposes. As a result, clinicians may assume that information-gathering interventions are ethically inappropriate and should not be used in innovative practice. This assumption can lead to seriously negative consequences, such as increasing the likelihood that harmful or ineffective innovations will be adopted and creating new barriers to the development of genuinely beneficial treatments. We argue that health care institutions need to promote the responsible use of information-gathering interventions as an adjunct to innovative practice, and that these interventions are not clinical research and should not be subject to research oversight. (shrink)

Background The health care sector is experiencing a drastic transition all over the world. This has an impact not only on the way hospitals, clinics, special-care homes etc. are organized, but also on patients, personnel and other stakeholders involved. The consequences of changes for both physicians and patients are investigated using a comprehensive health care reform in Ukraine as an example. Methods The analysis is based on empirical data collected from general physicians in 2 Ukrainian cities. Based on the Job (...) Demands-Resources Model, we developed a set of hypotheses and tested them using the structural equation modelling technique. A total of 178 general physicians (81% of the approached population) participated in the study. Results Our investigation reveals a clear relationship between the organizational job demands (additional tasks, structural changes, new processes) and their psychological effects (e. g., burnout). The latter have a negative impact on cooperation of physicians in hospitals leading to lower patient satisfaction. Discussion and Conclusions Change in health care is inevitable. The example of Ukraine shows that openness of hospitals towards change reduces the probability of physicians’ burnout and, eventually, increases patient satisfaction. We strongly suggest applying the process management approach in order to increase openness to change, especially in turbulent times. (shrink)

Timeliness, purposefulness, patient centeredness, consistency, and continuity are the general principles of rehabilitation and the defining tasks of developed countries, especially in the context of ensuring the realization of the rights and opportunities of people with disabilities. The purpose of the study was to identify the features of medical rehabilitation systems for persons with disabilities in the leading EU and NATO countries that have experience in rehabilitating combatants and to substantiate proposals for improving the current system of medical rehabilitation (...) in Ukraine. The study is based on the analysis of the conceptual principles of building rehabilitation systems in eight countries with developed democratic institutions, experience of military operations and belonging to classical models of social protection: Canada, France, Germany, Italy, Poland, Spain, the United Kingdom, the United States. The methods of comparative analysis, structural analysis, objectivity and consistency were used. The main results of the study are the identification of weaknesses of the Ukrainian medical rehabilitation system, such as fragmentation of service provision, lack of unified management coordination, insufficient information and uneven location of institutions. The advantages of foreign systems are analyzed: targeting medical rehabilitation, use of outsourcing, involvement of the community and volunteers, creation of competition between medical institutions, emphasis on mental rehabilitation, and use of sanatorium and resort facilities. It is proposed to create a single state body for coordinating medical services, develop a national roadmap for rehabilitation measures, encourage volunteers and expand the range of rehabilitation professions. The experience of the leading EU and NATO countries demonstrates the need for a systemic restructuring of medical rehabilitation in Ukraine through the introduction of modern approaches and methods aimed at improving the quality and accessibility of services. Successful implementation of foreign experience will create an effective national system capable of meeting the current challenges and needs of people with disabilities. (shrink)

Artificial agents (AAs), particularly but not only those in Cyberspace, extend the class of entities that can be involved in moral situations. For they can be conceived of as moral patients (as entities that can be acted upon for good or evil) and also as moral agents (as entities that can perform actions, again for good or evil). In this paper, we clarify the concept of agent and go on to separate the concerns of morality and responsibility of agents (most (...) interestingly for us, of AAs). We conclude that there is substantial and important scope, particularly in Computer Ethics, for the concept of moral agent not necessarily exhibiting free will, mental states or responsibility. This complements the more traditional approach, common at least since Montaigne and Descartes, which considers whether or not (artificial) agents have mental states, feelings, emotions and so on. By focussing directly on mind-less morality we are able to avoid that question and also many of the concerns of Artificial Intelligence. A vital component in our approach is the Method of Abstraction for analysing the level of abstraction (LoA) at which an agent is considered to act. The LoA is determined by the way in which one chooses to describe, analyse and discuss a system and its context. The Method of Abstraction is explained in terms of an interface or set of features or observables at a given LoA. Agenthood, and in particular moral agenthood, depends on a LoA. Our guidelines for agenthood are: interactivity (response to stimulus by change of state), autonomy (ability to change state without stimulus) and adaptability (ability to change the transition rules by which state is changed) at a given LoA. Morality may be thought of as a threshold defined on the observables in the interface determining the LoA under consideration. An agent is morally good if its actions all respect that threshold; and it is morally evil if some action violates it. That view is particularly informative when the agent constitutes a software or digital system, and the observables are numerical. Finally we review the consequences for Computer Ethics of our approach. In conclusion, this approach facilitates the discussion of the morality of agents not only in Cyberspace but also in the biosphere, where animals can be considered moral agents without their having to display free will, emotions or mental states, and in social contexts, where systems like organizations can play the role of moral agents. The primary cost of this facility is the extension of the class of agents and moral agents to embrace AAs. (shrink)

Introduction. The medical sphere is constantly evolving, requiring improved approaches to its organisation and functioning. Advances in medical technology, observable changes in patient needs and growing competition challenge medical institutions to improve their strategies and approaches. Marketing technologies are becoming one of the key tools for achieving strategic goals. Purpose. This article is aimed at studying the peculiarities of the use of marketing technologies in the medical field. The main purpose of the study is to analyse the impact of (...) marketing tools on the development and success of medical institutions. Method (methodology). The methodological approach involves the use of an analytical approach to studying current trends in marketing and their impact on the healthcare sector. The study uses methods of data analysis and comparative analysis of marketing practices in medical institutions. Results. The study found that the use of targeted marketing strategies allows healthcare facilities to attract more patients, increase customer satisfaction and ensure an excellent reputation. The results of the study show a positive impact of the use of marketing tools on changing the perception of medical services by patients. Conclusions. The scope of application of the results is the practical activities of medical institutions seeking to improve their strategy of promotion and interaction with customers. The findings of the study can be used by marketers and managers of healthcare organisations to develop and implement effective marketing strategies. In summary, this article reveals the importance of using marketing technologies in the healthcare sector and provides practical recommendations for their successful implementation. The study emphasises that marketing in the healthcare industry is necessary to increase competitiveness and ensure quality medical care. (shrink)

This paper adds another argument to the rising tide of panic about robots and AI. The argument is intended to have broad civilization-level significance, but to involve less fanciful speculation about the likely future intelligence of machines than is common among many AI-doomsayers. The argument claims that the rise of the robots will create a crisis of moral patiency. That is to say, it will reduce the ability and willingness of humans to act in the world as responsible moral agents, (...) and thereby reduce them to moral patients. Since that ability and willingness is central to the value system in modern liberal democratic states, the crisis of moral patiency has a broad civilization-level significance: it threatens something that is foundational to and presupposed in much contemporary moral and political discourse. I defend this argument in three parts. I start with a brief analysis of an analogous argument made in pop culture. Though those arguments turn out to be hyperbolic and satirical, they do prove instructive as they illustrates a way in which the rise of robots could impact upon civilization, even when the robots themselves are neither malicious nor powerful enough to bring about our doom. I then introduce the argument from the crisis of moral patiency, defend its main premises and address objections. (shrink)

The practice of medicine frequently involves the unconsented restriction of liberty. The reasons for unilateral liberty restrictions are typically that being confined, strapped down, or sedated are necessary to prevent the person from harming themselves or others. In this paper, we target the ethics of chemical restraints, which are medications that are used to intentionally restrict the mental states associated with the unwanted behaviors, and are typically not specifically indicated for the condition for which the patient is being treated. (...) Specifically, we aim to identify the conditions under which chemical restraints are ethically permissible. It is wrong to assume that what is morally true of physical restraints is also true of chemical restraints. Our aim is thus to identify the conditions under which chemical restraints are permissible while distinguishing these conditions from those of the application of physical restraints. (shrink)

The advancement of genome sequencing technology and its potential application in newborn screening is being discussed in various countries. Genomic newborn screening (gNBS) can provide parents with information about their child's genetic susceptibility for known disorders. However, it also presents ethical and psychosocial challenges. This study was carried out with a view toward the possible introduction of gNBS in Germany. Due to the existing challenges, it is crucial to understand different perspectives of relevant groups in Germany before implementing gNBS. Four (...) online focus groups were conducted with parents, patient representatives, and healthcare professionals to explore perceived opportunities and challenges, as well as needs regarding a potential gNBS program. Discussions with altogether 24 participants were semi-structured using a pre-defined interview guide. Sessions were audio-visually recorded and transcripts were analyzed using a structuring qualitative content analysis combining both deductive and inductive methods. Participants expressed positive views about gNBS but also reservations about a gNBS program and posed requirements for operating conditions. One salient theme that emerged was hope for certainty through gNBS in the face of numerous uncertainties. The study complements the perspective of patient representatives, providing further insight into the subject matter. This is a valuable contribution as they possess a comprehensive understanding of the medical, psychological, and ethical considerations involved. Patient representatives placed particular emphasis on the advantages of avoiding a diagnostic odyssey and the significance of support systems. The results provide first insights into different views on gNBS in Germany. These views can inform the potential preparation of a gNBS program in Germany, particularly with regard to information and consent requirements. Implications for practice, such as informing and educating parents about gNBS during pregnancy, can be derived from the study. WHAT IS KNOWN ABOUT THIS TOPIC: Previous studies have indicated that there is significant public and—more particularly parental—interest in genomic newborn screening (gNBS). However, discrepancies exist regarding preferences for the scope of reported results, including differences between the views of healthcare professionals, parents, and the public. WHAT THIS PAPER ADDS TO THE TOPIC: This study offers insights into various perspectives on the potential implementation of gNBS in Germany, highlighting divergent views of healthcare professionals and parents, while also introducing a novel and valuable contribution by including the viewpoints of patient representatives. (shrink)

Suppose some person 'A' sets out to accomplish a difficult, long-term goal such as writing a passable Ph.D. thesis. What should you believe about whether A will succeed? The default answer is that you should believe whatever the total accessible evidence concerning A's abilities, circumstances, capacity for self-discipline, and so forth supports. But could it be that what you should believe depends in part on the relationship you have with A? We argue that it does, in the case where A (...) is yourself. The capacity for "grit" involves a kind of epistemic resilience in the face of evidence suggesting that one might fail, and this makes it rational to respond to the relevant evidence differently when you are the agent in question. We then explore whether similar arguments extend to the case of "believing in" our significant others -- our friends, lovers, family members, colleagues, patients, and students. (shrink)

Known as self-illness ambiguity, subjective confusion about whether patients or their mental illnesses are in control may partly stem from clinical methods mimicking medical models that diagnose illnesses (e.g. viruses) as present or not irrespective of sufferers’ life stories. Researchers accordingly propose narrative contextualization as a way of disambiguating self from illness. But what if heightened self-attention is symptomatic of mental illness? Wellbeing may then associate with a smaller ‘me’ versus ‘not-me’ divide, a position Csikszentmihalyi’s flow psychology and Dewey’s aesthetics (...) both support. What I call aesthetic flow involves embodied, non-linguistic dramatic structure, suggesting another way to view narrativity. By lessening self-preoccupation – and perhaps illness severity – this kind of narrativity may help dissolve self-illness ambiguity. However, a perplexity remains. Aesthetic flow depends on encountering resistance, including psychological obstacles. In life, as in art, this resistance delineates and individuates. Thus, aesthetic flow might lead to a temporary loss of self, followed by its reemergence in more immersively relational forms. A second complexity is that experiences of ‘self’ vary across time, cultures, and individuals – much like concepts of ‘justice’ or ‘love.’ This fluidity makes broad generalizations about selfhood and illness problematic. My solution partly sidesteps this by downplaying the importance of self. (shrink)

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. (...) I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (shrink)

How does doubt come about? What are the mechanisms responsible for our inclinations to reassess propositions and collect further evidence to support or reject them? In this paper, I approach this question by focusing on what might be considered a distorting mirror of unreasonable doubt, namely the pathological doubt of patients with obsessive–compulsive disorder (OCD). Individuals with OCD exhibit a form of persistent doubting, indecisiveness, and over-cautiousness at pathological levels (Rasmussen and Eisen in Psychiatr Clin 15(4):743–758, 1992; Reed in Obsessional (...) experience and compulsive behaviour: a cognitive-structural approach, Academic Press, Cambridge, 1985; Tolin et al. in Cogn Ther Res 27(6):657–669, 2003). I argue that the failure in OCD is of an affective nature, involving both excessive epistemic anxiety and hyperactive feelings of uncertainty. I further argue that our adaptive disposition to inquire about the right matters—that is, about propositions which are both epistemically risky and imply harmful possibilities—might depend on these affective mechanisms. (shrink)

This paper aims to clarify the nature of understanding in medicine. The first part describes in more detail what it means to understand something and links a type of understanding (i.e., objectual understanding) to explanations. The second part proceeds to investigate what objectual understanding of a disease (i.e., biomedical understanding) requires by considering the case of scurvy from the history of medicine. The main hypothesis is that grasping a mechanistic explanation of a condition is necessary for a biomedical understanding of (...) that condition. The third part of the paper argues that biomedical understanding is necessary, but not sufficient for understanding in a clinical context (i.e., clinical understanding). The hypothesis is that clinical understanding combines biomedical understanding of a _disease_ or pathological condition with understanding _illness,_ which involves some degree of personal understanding of the patient. It is argued that, in many cases, clinical understanding necessitates adopting a particular second-personal stance and using cognitive resources _in addition_ to those involved in biomedical understanding. (shrink)

Most psychotherapeutic approaches are, to a greater or lesser extent, rooted in the theories and principles of scientific psychology. Nevertheless, in-session psychotherapeutic interaction between a therapist and a client is, at its core, a folk-psychological practice. As such, it is based on folk-psychological skills and competencies. But which ones exactly? This chapter argues that, while we may initially be inclined to perceive the practice of psychotherapy as primarily involving sophisticated mindreading on the part of both the therapist and the client/ (...) class='Hi'>patient, a complete characterization of psychotherapy must give at least the same amount of attention to different forms of therapeutic mindshaping. Using examples drawn from multiple therapeutic traditions, I illustrate how therapeutic mindreading and mindshaping interact. I conclude by highlighting some of the consequences of this perspective for the ethics and politics of psychotherapy. (shrink)

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion (...) has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice. (shrink)

Objectives: Machine learning (ML) has the potential to facilitate “continual learning” in medicine, in which an ML system continues to evolve in response to exposure to new data over time, even after being deployed in a clinical setting. In this article, we provide a tutorial on the range of ethical issues raised by the use of such “adaptive” ML systems in medicine that have, thus far, been neglected in the literature. -/- Target audience: The target audiences for this tutorial are (...) the developers of ML AI systems, healthcare regulators, the broader medical informatics community, and practicing clinicians. -/- Scope: Discussions of adaptive ML systems to date have overlooked the distinction between 2 sorts of variance that such systems may exhibit—diachronic evolution (change over time) and synchronic variation (difference between cotemporaneous instantiations of the algorithm at different sites)—and underestimated the significance of the latter. We highlight the challenges that diachronic evolution and synchronic variation present for the quality of patient care, informed consent, and equity, and discuss the complex ethical trade-offs involved in the design of such systems. (shrink)

We are sometimes unsure of the moral status of our relationships with other entities. Recent case studies in this uncertainty include our relationships with artificial agents (robots, assistant AI, etc.), animals, and patients with “locked-in” syndrome. Do these entities have basic moral standing? Could they count as true friends or lovers? What should we do when we do not know the answer to these questions? An influential line of reasoning suggests that, in such cases of moral uncertainty, we need meta-moral (...) decision rules that allow us to either minimize the risks of moral wrongdoing or improve the choice-worthiness of our actions. One particular argument adopted in this literature is the “risk asymmetry argument,” which claims that the risks associated with accepting or rejecting some moral facts may be sufficiently asymmetrical as to warrant favoring a particular practical resolution of this uncertainty. Focusing on the case study of artificial beings, this article argues that this is best understood as an ethical-epistemic challenge. The article argues that taking potential risk asymmetries seriously can help resolve disputes about the status of human–AI relationships, at least in practical terms (philosophical debates will, no doubt, continue); however, the resolution depends on a proper, empirically grounded assessment of the risks involved. Being skeptical about basic moral status, but more open to the possibility of meaningful relationships with such entities, may be the most sensible approach to take. (shrink)

Intelligent neurotechnology is an emerging field that combines neurotechnologies like brain-computer interface (BCI) with artificial intelligence. This paper introduces a capability framework to assess the responsible use of intelligent BCI systems and provide practical ethical guidance. It proposes two tests, the threshold and flourishing tests, that BCI applications must meet, and illustrates them in a series of cases. After a brief introduction (Section 1), Section 2 sets forth the capability view and the two tests. It illustrates the threshold test using (...) examples from clinical medicine of BCI applications that enable patients with profound disabilities to function at a threshold level through computer mediation. Section 3 illustrates the flourishing test by exploring possible future applications of BCI involving neuroenhancements for healthy people, using examples adapted from research currently underway in the US military. Section 3 applies a capability lens to a complex case involving dual effects, both therapeutic and non-therapeutic, showing how the threshold and flourishing tests resolve the case. Section 4 replies to three objections: neurorights are the best tool for assessing BCI; the two tests are moving targets; and the analysis utilizes a capability view to do work it is not designed for. The paper concludes that a capability view offers unique advantages and gives practical guidance for evaluating the responsible use of present and future BCI applications. Extrapolating from our analysis may help guide other emerging technologies, such as germline gene editing, expected to impact central human capabilities. (shrink)

The profound changes in personality, mood, and other features of the self that neural interventions can induce can be disconcerting to patients, their families, and caregivers. In the neuroethical debate, these concerns are often addressed in the context of possible threats to the narrative self. In this paper, I argue that it is necessary to consider a dimension of impacts on the narrative self which has so far been neglected: neural interventions can lead to a loss of meaning of actions, (...) feelings, beliefs, and other intentional elements of our self-narratives. To uphold the coherence of the self-narrative, the changes induced by neural interventions need to be accounted for through explanations in intentional or biochemical terms. However, only an explanation including intentional states delivers the content to directly ascribe personal meaning, i.e., subjective value to events. Neural interventions can deprive events of meaning because they may favor a predominantly biochemical account. A loss of meaning is not inherently negative but it can be problematic, particularly if events are affected one was not prepared or willing to have stripped of meaning. The paper further examines what it is about neural interventions that impacts meaning by analyzing different methods. To which degree the pull towards a biochemical view occurs depends on the characteristics of the neural intervention. By comparing Deep Brain Stimulation, Prozac, Ritalin, psychedelics, and psychotherapy, the paper identifies some main factors: the rate of change, the transparency of the causal chain, the involvement of the patient, and the presence of an acute phenomenological experience. (shrink)